374603394-4-6-2022-08-AS-KHIO-CD92GC-20220406172251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603394
Report Date: 04/06/2022
Date Signed: 04/06/2022 05:23:01 PM

Document Has Been Signed on 04/06/2022 05:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	SUNRISE ASSISTED LIVING AT BONITA		FACILITY NUMBER:	374603394
ADMINISTRATOR:	GOODING, ROXANNE		FACILITY TYPE:	740
ADDRESS:	3302 BONITA RD		TELEPHONE:	(619) 470-2220
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	96	CENSUS: 61	DATE:	04/06/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Business Office Coordinator, Marleth Guerrero		TIME COMPLETED:	05:30 PM

NARRATIVE

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Licensing Program Manager (LPM), John Rante, and Licensing Program Analyst, Kayla Hilario, conducted an unannounced case management visit to cite a background check deficiency. LPM and LPA were allowed entry by the reception and met with Business Office Coordinator, Marleth Guerrero, and discussed the purpose of the visit.

During a recent investigation, it was discovered that Staff #1 (S1) was hired by the facility and worked from December 20, 2021 through February 7, 2022. Facility staff were able to produce FBI clearance and their own background clearance but were unable to produce Department approval for allowing S1 to begin work. Form LIC 811 – Confidential Names Forms identifies S1.

A civil penalty is being issued today in violation of Title 22 regulations in the amount of $500 on form LIC 421BC.

In addition, LPM and LPA obtained additional information for the Case Management Visit on 3/15/2022.

An exit interview was conducted with Business Office Coordinator, Marleth Guerrero. A copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to the Business Office Coordinator via hard copy at the conclusion of the visit.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla Hilario	TELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/06/2022 05:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNRISE ASSISTED LIVING AT BONITA	FACILITY NUMBER: 374603394
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/07/2022 Section Cited	1 2 3 4 5 6 7	All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(e)(2). This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on documentation provided by facility, interviews, and observations, 1 (S1) out of 88 staff were not transferred or associated with Department approval prior to beginning work. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla Hilario	TELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

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